Healthcare Provider Details

I. General information

NPI: 1508860487
Provider Name (Legal Business Name): JACK T PETERSON JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 04/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

631 SW HORNE ST STE 400
TOPEKA KS
66606-1661
US

IV. Provider business mailing address

631 SW HORNE ST STE 400
TOPEKA KS
66606-1661
US

V. Phone/Fax

Practice location:
  • Phone: 785-234-9000
  • Fax: 785-234-9119
Mailing address:
  • Phone: 785-234-9000
  • Fax: 785-234-9119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number0422259
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: